Dysautonomia Formulary

Please take note of the following prior to using this formulary: Most of these medications are not FDA approved for the treatment of dysautonomia, particularly in the pediatric population. The dosage information provider here is a combination of recommendations from the Pediatric Dosing Handbook Formulary and expert opinion. It is important for this dosing information to be used with caution and only after full review of the entire dysautonomia module. We highly encourage you to discuss medication dosing with a pharmacist and/or pediatric physiatrist if you have any questions or concerns.

BROMOCRIPTINE Starting Dose How to Titrate Maximum Dose Onset Age<2 years: 0.625mg PO BID Age>2 years: 1.25mg PO BID Can start with daily dosing if conservative How to Titrate Double the dose 1-2 times/week until you have reached the desired effect Maximum Dose Children: 12.5mg BID Adults: 25mg BID Onset 1-2 hours Half-life 15 hours BROMOCRIPTINE Propanalol Labetalol Diazepam Clonidine Clonazepam Bromocriptine

CLONAZEPAM Starting Dose How to Titrate Maximum Dose Onset Half-life 0.01-0.03mg/kg/day divided BID Maximum STARTING dose: 1.5mg/day How to Titrate Increase dose by up to 0.5mg q3 days Maximum Dose 0.2mg/kg/day OR 20mg/day Onset 20-60 minutes Half-life 22-33 hours Other Clonazepam should generally be used twice daily however it can be given up to 4 times a day. If a patient requires more frequent dosing then consider adding other medications as increased frequency will “snow” the patient. If you are titrating the dose upward, start with nighttime dose due to the cognitive suppressive effects. CLONAZEPAM Propanalol Labetalol Diazepam Clonidine Clonazepam Bromocriptine

CLONIDINE Starting Dose How to Titrate Maximum Dose Onset Half-life 5-10 MICROGRAMS/kg/day divided q8-12 hours How to Titrate Gradually to 5-25 MICROGRAMS/kg/day divided every 6 hours. Monitor blood pressures closely. Maximum Dose 0.9mg/day Onset Oral: 30-60 minutes Half-life 8-12 hours Other Some transdermal patches can be cut in half however, half of a 0.1mg patch cannot be considered 0.05mg, it must be considered a ½ patch because exact dosing cannot be guaranteed. The patch may take up to 2-3days to reach therapeutic levels. Once removed, therapeutic levels may persist for 8-12 hours and will then slowly decline over 24-48hours. CLONIDINE Propanalol Labetalol Diazepam Clonidine Clonazepam Bromocriptine

DIAZEPAM Starting Dose How to Titrate Maximum Dose Onset Half-life PO or IV/IM: 0.05-0.1mg/kg/dose q6-8hrs How to Titrate If no effect after 1st dose then repeat in 30 min Re-eval frequently to assess efficacy and increase dose or frequency as needed Maximum Dose 0.6mg/kg in 8hrs May consider higher doses in consultation with PM&R and/or the ICU due to risk of respiratory depression Onset IV: 1-3minutes Rectal: 2-10 minutes Half-life Age 1mo-2yrs: 40-50 hours Age 2-16yrs: 15-21 hours Other Monitor for respiratory depression The half-life of the active metabolite that causes respiratory depression is 50-100 hours DIAZEPAM Propanalol Labetalol Diazepam Clonidine Clonazepam Bromocriptine

LABETALOL Starting Dose How to Titrate Maximum Dose Onset Half-life 0.2-0.5mg/kg/dose with range of 0.2-1mg/kg/dose How to Titrate Discuss with physiatrist and pharmacist Maximum Dose 20mg/dose Onset (IV): 2-5 minutes Half-life (IV) 5-8 hours Labetolol Propanalol Labetalol Diazepam Clonidine Clonazepam Bromocriptine

PROPRANALOL Starting Dose How to Titrate Maximum Dose Onset Half-life 0.25-0.5mg/kg/day divided BID How to Titrate Increase dose by 2.5-5mg/dose Maximum Dose 30mg q6 hours Onset 1-2 hours Half-life 4-6 hours Other Can initiate at an interval of every other day if conservative. At greater than maximal doses, will cause bronchospasm that is unresponsive to beta agonists. When titrating, if no response in heart rate, increase the next dose or increase q1-2 days by the increment noted above—usual dose is 1-5mg/kg/day. Look at heart rate to gauge how well it is working PROPRANOLOL Propanalol Labetalol Diazepam Clonidine Clonazepam Bromocriptine